Serves 1
Ingredients:
- 1 Peach
- 1 Mango
- 1 small banana
- 1 tablespoon of plain yogurt
- ½ teaspoon of vanilla extract (optional)
- Handful of ice
Blend and serve
Serves 1
Ingredients:
Blend and serve
Mexican Shrimp Salad with avocado, black beans, and cilantro
Serves 2
oss the shrimp with 2 tablespoons olive oil and salt. Meanwhile, heat a large sauté pan over a medium flame. Add the shrimp to the pan in an even layer, and sear until fully cooked, about 1-2 minutes per side.Transfer to a plate.
Vegetarian alternative: Don’t add shrimp
Serves 2
Ingredients:
Tuna prep:
Rub medium sauté pan with a cloth containing some olive oil and heat over a medium flame. Sprinkle both sides of each tuna steak with Celtic salt and place in the hot pan. Sear for about 1 minute on each side, keeping the center rare. Remove from the heat and slice.
Salad/meal prep:
Toss together the romaine, eggs, green beans, olives, carrots, cucumber, basil, parsley, teaspoon olive oil, and ¼ teaspoon of salt. Top with the seared tuna and serve.
Notes:
For a vegetarian option, don’t add tuna.
Roasted Beets and Fresh Cucumber with Creamy White Bean Dip
Serves 2
Preheat oven to 350° F. Wash, trim, and dry the beets. Cut them in half for quicker cooking and place them on a large sheet of aluminum foil. Add 2 teaspoons olive oil and ¼ teaspoon of salt. Rub in the oil and salt and evenly coat. Wrap the aluminum tightly around the beets. Place on a baking sheet and roast until fork tender, about 20-30 minutes, depending on the size of the beets. Let them cool, then rub a paper towel over them to remove the skins.
Rinse one cup of dried cannellini beans and clean thoroughly. Place the beans in a large bowl and cover with water. Let soak overnight. The next day, strain and rinse them, then place in a medium sauce pan and cover with water. Add a big pinch of salt, bring to a boil, and reduce to a simmer with the lid on. Cook for about 40-50 minutes, or until soft, but not mushy. Drain and rinse well. Let cool.
If you are using beans from a can, please make sure the product is organic. Organic canned beans should only contain water, salt, and beans. To use canned beans for this recipe, just open the can, rinse the beans slightly, and add to recipe.
Place the cannellini beans in a food processor with the water, olive oil, and salt. Purée until smooth, then stir in the dill. Serve with the sliced beets and cucumbers.
Serves 1
Preheat the oven to 450° F. Place the chicken in a pan and sprinkle with olive oil and a pinch of salt. Place the pan in the oven and roast for about 10-15 minutes, flipping the chicken occasionally. After cooked, let the chicken cool, then chop into small cubes.
If using frozen corn or green beans, defrost them by placing them in boiling water for about 1-2 minutes. Next, drain corn or green beans well, let them cool off for a few minutes, then chop the green beans finely and mix them with the chicken.
Blend the Bragg Liquid Aminos and honey together. Then add to the chicken and mix it in well. Add a pinch of salt if necessary.
For a delicious, healthy, replenishing, non-acidic, AcidWatcher-safe smoothie try the Dr. Aviv Smoothie:
Serves 1
TNE stands for TransNasal Esophagoscopy. It is a method of examining the esophagus, the structure that connects the throat to the stomach, without putting someone to sleep or giving any sedation. The traditional method of examining the esophagus was to place a large round camera, think of a garden hose, through the mouth then into the esophagus and stomach. One has to be sedated with intravenous medication or medication in the vein, so that one doesn’t gag during the procedure. The gag reflex is actually located in the mouth. However, by going through the nose one bypasses the gag reflex. So by using an ultrathin camera, the size and texture of a cooked piece of spaghetti, the gag reflex can be bypassed, and the esophagus can then be examined without having to sedate or knock out the patient. It’s much safer for the patient as almost all the risks of upper endoscopy are not related to the procedure itself, but to the sedation administered during the procedure. So people should be aware that there are alternatives to traditional sedated endoscopy.
TNE is one-fifth the cost of traditional sedated endoscopy. TNE is performed not only by ENT doctors but by gastrointestinal doctors as well. To understand the potential positive impact of awake upper endoscopy or an unsedated exam of the food pipe, there are approximately 10 million upper endoscopies performed each year in the United States. The facility fee, that which the insurance companies, including medicare and medicaid, pay when the procedure is done under sedation, averages an extra $1000/ procedure. Or 10 Billion dollars a year. Conservatively, half of these procedure could be done with the patient awake, therefore saving us taxpayers 5 billion a year. Even more important is the greater patient safety when people don’t need to undergo sedation. TNE is a medical advance exemplifying one of those rare situations where not only can the entire healthcare industry save money, but it is much safer for patients.
Are there alternatives to sedation for those needing an upper endoscopy, or does everyone have to be sedated?
There are almost 10 million upper endoscopies performed annually in the USA. Upper endoscopy is the insertion of a camera through your mouth to look at your esophagus and stomach, generally done when someone has complaints of chronic heartburn. In general, one needs to be sedated with a twilight type of anesthesia during an upper endoscopy. However, conscious sedation is not necessarily a free ride. There are small but finite risks associated with conscious sedation, namely problems with the heart (heart attack) and lungs (stopping breathing) that can take place.
Most people are not aware that there are certain circumstances where sedation may not be necessary, especially when one only needs to examine the esophagus (the tube that connects the throat to the stomach). This procedure is called TransNasal Esophagoscopy(TNE), where an ultrathin camera, the size and softness of a piece of cooked spaghetti, is performed with the patient wide awake, in a doctor’s office, only requiring a small amount of numbing medicine misted into the nose.
The indications for a TNE are the following:
The contraindications to performing a TNE, i.e. TNE is not the right exam, rather a sedated upper endoscopy is the more appropriate exam, are:
TNE: Myths and Facts
MYTH #1: TNE is not as well tolerated as conventional endoscopy (EGD).
FACT: From 1996 until now, there have been numerous studies comparing TNE and EGD, demonstrating that patients can tolerate a camera in their nose as well as they tolerate a camera in their mouth.
MYTH #2: TNE is not as effective as EGD.
FACT: Unsedated TNE has demonstrated equal accuracy in the detection of Barrett esophagus when compared with conventional, sedated, transoral upper endoscopy.
MYTH #3: TNE is expensive.
FACT: TNE is one-fifth the cost of EGD.
MYTH #4: TNE will increase our national health care costs.
FACT: TNE can save the health care industry about $5 billion per year.
MYTH #5: TNE has side effects.
FACT: Beyond the potential for a nosebleed, TNE is exceedingly safe.
Barrett esophagus is a potentially pre-cancerous condition typically appearing in the area where the lower part of the esophagus joins the stomach.
A normal, healthy stomach has an intense pinkish color, like smoked salmon or lox, while the esophageal lining has a grayish-white color. Generally, the pink stomach lining begins where the grayish-white esophagus ends. However, when there is severe acid injury to the bottom portion of the esophagus, the stomach lining starts to creep up into the esophagus, resulting in finger-like projections of pinkish tissue jutting into the grayish-white esophageal lining.
Barrett esophagus, or the presence of stomach tissue in the esophagus, is a dangerous sign for patients. It places that individual at a higher risk of developing esophageal cancer. In fact, those with Barrett esophagus are 30 to 125 times more likely to develop esophageal adenocarcinoma than the general population.
Barrett esophagus currently affects roughly 1% of adults in the United States. Men typically develop Barrett twice as often as women, and it is most common in white males over 50. However, over the past 10 years, I have been seeing men and women in their 40’s, 30’s, and even some in their 20’s with this condition. In the past 6 months alone I diagnosed Barrett in 3 people under the age of 28 (24, 26, and 28) all of whom had chronic hoarseness, but without heartburn.
About 8% of patients with Heartburn Reflux (GERD) have Barrett esophagus. Ominously, up to 10-15% of Throatburn Reflux (LPR) patients, those who have no heartburn but do have chronic symptoms of cough, hoarseness, lump-like sensation in throat, and throat clearing, have Barrett esophagus. By “chronic symptoms” I’m referring to symptoms lasting longer than eight weeks.
The unfortunate reality regarding esophageal cancer is that most people are at an advanced stage of the disease at the time they are diagnosed, with the survival rate usually being less than one year. The only way to make a dent in this disease is to catch it before it starts, and that is while it is still in its pre-cancerous, Barrett esophagus stage.
However, the current paradigm for examining patients for esophageal cancer dictates that essentially only people who complain of heartburn should be examined for Barrett esophagus. Yet this approach is ineffective in preventing the cancer since the majority of people with Barrett esophagus don’t experience heartburn due to the numbness of the esophageal tissue caused by acid damage over the years. Studies have shown that people who have Throatburn reflux symptoms are at higher risk of developing esophageal adenocarcinoma (the type of esophageal cancer caused by acid reflux damage) so that SYMPTOMATIC group is who should definitely be examined.
Post nasal drip (PND) refers to the sensation of mucus or secretions coming down from the back of one’s nose into their throat. PND is classically seen in people with allergies and sinus disease, but it is also one of the most common symptoms of Throatburn reflux.
The body normally produces between 1-2 liters of mucus a day from the nose and sinuses. This fluid, typically unnoticed, is distributed over a 24 hour period and is generally swallowed without incident. However, if there is blockage in the nose, sinuses or throat, the “drip” sensation becomes noticeable and complaints invariably ensue.
The drip sensation occurs frequently in people with Throatburn reflux because the back portion of the larynx swells in response to constant acid exposure, either from acid coming up from the stomach or from activation of pepsin receptors in the throat directly from acidic foods (processed foods, sugary soda, citrus, tomato, vinegar) which in turn will cause swelling of throat tissues.
The treatment of PND is directed towards relieving the areas of obstruction, In the case of a nose/sinus source of the drip, often a food and an environmental allergy investigation is warranted. Occasionally, an imaging study of the paranasal sinuses, either a CT scan or an MRI, is carried out so the anatomy of the nose and sinuses can be figured out.
In the situation where there is no significant nose and sinus disease, and there is swelling of the larynx, then treatment of acid reflux disease – diet, lifestyle and occasionally medications – should take place.
Globus is a Latin word for globe or sphere, which is what people often describe when they come in to see me complaining of a lump-like sensation in their throat. It is one of the most common complaints I see on a daily basis and is a very uncomfortable and troubling symptom for patients because they often feel like something is always present in their throat, or something is stuck in their throat, especially when they are swallowing. While there is a known entity in the psychiatric scientific literature of something called “globus hystericus” (the implication being that the lump-like sensation is because of psychological issues), I believe that almost all “globus” complaints are not in someone’s head, but truly in someone’s throat.
The important thing to do when a complaint of globus presents itself is to figure out what’s causing the lump-like sensation which will then allow proper treatment to take place. The first step is the patient’s history. How long has the sensation been going on? A globus sensation that has been going on for several days often suggests either an infection or some type of allergic response. A globus sensation taking place for months suggests a more chronic process such as acid reflux disease, a nerve injury in the throat, or even a tumor. For example, if the lump-like sensation been getting worse and worse then a situation of worsening symptoms is always worrisome and underscores the importance of taking this symptom seriously. What circumstances, if any, were associated with the onset of the globus sensation? A globus sensation associated with eating certain foods or after a bad cold or flu, can further direct the attention of your health care professional to the source of the problem. What makes it better? What makes it worse?
Diet and lifestyle history are also critical items to know. As far as diet, I always ask about 10 types of foods, 4 common acidic foods such as soda, citrus (lemon, lime, pineapple, orange, grapefruit), tomato and vinegar. Then about 6 common foods while not in and of themselves generally very acidic, but have effects on digestion that can cause problems for those who might have acid reflux disease, such as caffeine, chocolate, alcohol, mint, onion and garlic. Those 6 commonly consumed foods share the following trait, they all are powerful relaxers of the muscle that separates the stomach from the esophagus, called the lower esophageal sphincter (LES). Caffeine, which is often in chocolate as well, has the additional property of increasing acid production by the stomach. So caffeine and chocolate can not only loosen the protective muscular barrier between the acidic stomach and its adjacent structure, the esophagus, it can also increase acid production by the stomach, a physiologic “one-two punch” that can create misery for people, as acid from the stomach can then freely travel up the esophagus towards the throat.
Lifestyle history is also key. Eating late at night then lying down to sleep, or lying down right after eating are very common risk factors for the development of globus type symptoms. Smoking any substance is important to know as well, as smoking directly irritates the throat and, depending on what you are smoking, nicotine for example, can also have physiologic effects that loosen the stomach–esophagus barrier. Further, and this is always my greatest concern when I see patients who smoke or have a past history of smoking, there is always the risk of cancer in the head and neck and esophagus when smoking is part of the mix.
So once a thorough history is established, it is then important to examine the patient to see what is going on in their throat that might be causing their globus complaint. Examining the neck to make sure there are no lumps or bumps is essential. Then examining the nose, mouth, back of the throat, tongue, gums and teeth takes place. Abnormalities in those areas may give a hint as to the cause of the lump-like sensation. For example, in someone who has a few days of a lump-like sensation and a red throat on exam, that points more to an infection as the cause. On the other hand, if a mass is seen in the tonsil or tongue area, then that points to a tumor as a possible cause.
Generally, the most effective way to see what’s taking place in the throat itself is to use a tiny camera that is passed via the patients nose into their throat to actually visualize the throat structures in real time. This office-based procedure is called Transnasal Flexible Laryngoscopy (TFL) and allows the physician to see exactly what is going on in a patients throat, tongue, vocal fold area, top of the esophagus and top part of the windpipe. With TFL one can see if indeed there is swelling in the throat that’s causing the lump-like sensation. Nerve injury, tumor, consequences of allergies can all be determined with this type of exam. By far the most common cause of a globus sensation is acid reflux from the stomach, called Throatburn reflux. Also known as LPR (LaryngoPharyngeal (Lah-ringo faren gee uhl) Reflux), sometimes called “silent” reflux or “airway” reflux. I am not fond of the term “silent” (meaning no heartburn) reflux because the symptoms of a lump-like sensation in the throat is rarely silent as my patients are often constantly clearing their throat and coughing to clear their throats of that lump-like sensation.
Hoarseness is defined as a raspy or strained voice which can be due to many causes. One of the most common causes of hoarseness is voice overuse, misuse or abuse. Generally people who use their voice a great deal often have voice problems, such as parents of young children, teachers, clergy, and professional singers, actors and performers.
However, in addition to length of time talking and the style of how one speaks, other factors may play a role in the development of voice issues, in particular acid reflux disease. Stomach acid can affect the voice in two different ways, either from acid reflux coming up from the stomach, or from acidic foods coming down from the mouth after being swallowed and then directly irritating the throat and vocal folds. The direct injury to the vocal fold is via “tissue bound pepsin” that gets activated in acidic environments, such as when drinking sugary sodas, eating processed foods, citrus fruits (pineapple, orange, grapefruit, lemon, lime), vinegar, and tomato.
The vocal folds can also be directly irritated from noxious, carcinogenic substances like cigarette or cigar smoke.
Another cause of hoarseness may be some type of bump or tumor on the vocal fold itself, or even from a vocal fold that is not moving well, for example a paralyzed vocal fold.
To properly treat the hoarseness requires an accurate diagnosis of why the individual is hoarse. The best way to make an accurate diagnosis is to have a look at the vocal folds in action via tests ear, nose and throat (ENT) doctors perform, called Transnasal Flexible Laryngoscopy (TFL) or Laryngeal Videostroboscopy. Each test uses some type of ultra-thin flexible or rigid camera to look at the vocal folds moving in real time with the patient wide awake.
Once the cause of the hoarseness is determined then treatment is tailored to the source of the problem. Very commonly, acid reflux disease, generally the Throatburn reflux type, also know as LaryngoPharyngeal Reflux (LPR) or “silent“ reflux, can either cause, or contribute to, the hoarseness as a result of the vocal folds being swollen by acid injury. The treatment is typically multifaceted, often including a form of physical therapy called Speech Therapy, in addition to dietary and medical therapies. Dietary treatment requires low acid diets, along with certain lifestyle changes such as avoiding late night eating and staying up for at least 3 hours after one’s last meal.
Chronic cough, defined as cough lasting for more than 8 weeks, is the most common reason patients see a doctor in the United States. It is responsible for 28 million patient visits per year, more than twice the incidence of the next most common complaint, headache. It is one of the most misdiagnosed symptoms in medicine.
While chronic cough is one of the classic symptoms of Throatburn Reflux, in order to determine the precise source of one’s cough there is a very basic algorithm that one should follow.
When you have a chronic cough, the first thing you should do is stop smoking. Next, check your medications, as some medications themselves can cause cough. Then, problems with the lungs, allergies, nose, and sinuses should be ruled out as the source. If ruled out, turn attention to your throat where an ear, nose and throat (ENT) exam is performed using an ultra-thin camera, the size and softness of a cooked piece of spaghetti, called Transnasal Flexible Laryngoscopy (TFL). The most common cause of unexplained cough is acid reflux disease, specifically Throatburn Reflux (or LaryngoPharyngeal Reflux (LPR), also sometimes called “silent” reflux or “airway” reflux).
If signs of acid reflux are seen, a low acid, high fiber, nutritionally balanced diet such as the Acid Watcher® Diet and medical treatment is used. Also, because of the chronic cough, a TransNasal Esophagoscopy (TNE) should be performed to make sure no pre-cancerous conditions exist in the esophagus.
After acid reflux is considered and ruled out, you must then consider either nerve injury to the vocal cords, or a tumor on the vocal cords, or even vocal cord dysfunction (VCD, also known as paradoxical vocal fold movement disorder (PVFMD)) as the source of the cough. If a nerve injury such as a vocal fold paralysis is seen, then imaging such as an MRI of the neck is performed to make sure there is no tumor pressing on the nerve in the neck that moves the vocal fold. If a tumor is seen on the vocal fold during the exam of the throat, then a biopsy of the tumor should take place. Finally, if VCD is seen, which is a vocal fold movement pattern where the vocal folds start to close during quiet breathing, as opposed to the normal circumstance where they essentially stay open during quiet breathing, then appropriate treatment should commence.
Throatburn reflux is a term that I coined that means acid reflux disease without the classic symptoms of heartburn and regurgitation. Throatburn reflux also goes by the medical term LaryngoPharyngeal Reflux (LPR). Remarkably, 90% of the patients in my practice have Throatburn reflux. So instead of heartburn, patients complain of chronic cough, hoarseness, excessive throat clearing, and a lump-like sensation in the throat. I prefer the term “Throatburn reflux” more than the term “silent reflux” because there is nothing silent about a patient clearing their throat, coughing or having a raspy voice.
I also call Throatburn reflux symptoms “ALARM” symptoms, which means that acid injury has likely been going on so long that people are numb in their stomach and esophagus, yet still feel changes in their throat. So one needs to have their throat and esophagus examined to make sure there are no signs of severe inflammation in the esophagus or, potentially, pre-cancerous changes in the esophagus, a condition called Barrett Esophagus.
Heartburn is best described as a burning sensation in the bottom of the chest and ribcage that can expand into the middle of the chest area toward the throat.
When the esophagus is irritated, one can experience a burning sensation in the chest, commonly referred to as heartburn. The term “heartburn” doesn’t mean an actual heart condition. It simply refers to the fact that the pain resulting from acid injury to the esophagus emanates from an area where the heart sits anatomically. This condition is referred to as GastroEsophageal Reflux Disease (GERD). Regurgitation, the other typical symptom of GERD, is the sensation of food coming back up into your chest and throat after you’ve already swallowed it.
Some important points about Heartburn reflux or GERD:
The traditional way to examine the esophagus had been to place a large camera in the mouth and guide it past the throat into the esophagus. Because the camera went through to the back of the mouth, where the powerful gag reflex is located, we needed to give patients intravenous sedation to negate the effects of the gag reflex. With TNE, an ultra-thin camera the size and softness of a cooked piece of spaghetti, is placed via the nose into the throat area, then into the esophagus. By going through the nose, the doctor bypasses the back of the mouth, so the gag reflex isn’t stimulated.
Because you don’t have to worry about the gag reflex with TNE, patients don’t need intravenous sedation (also known as conscious sedation or “twilight” anesthesia). Because the patient is awake, the procedure is much safer, there’s also no need for expensive monitoring, and the patient can go back to work or to play right after the procedure.
TNE is less expensive and more convenient than traditional sedated upper endoscopy and numerous studies have shown that TNE is as safe as traditional sedation upper endoscopy, as well-tolerated by the patient, and as good at detecting potentially precancerous tissue. Most people have never heard of TNE, but in the past 10 years, more doctors are using this technique and residency training programs are teaching it.